FHIR Implementation Guide for the Norwegian Municipal Sector - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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: Municipal journey: plan with assessment basis and follow-up

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{
  "resourceType" : "CarePlan",
  "id" : "example-kpr-careplan",
  "meta" : {
    "profile" : [
      🔗 "https://kommune.conteir.no/StructureDefinition/kommune-careplan"
    ]
  },
  "language" : "en",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p class=\"res-header-id\"><b>Generated Narrative: CarePlan example-kpr-careplan</b></p><a name=\"example-kpr-careplan\"> </a><a name=\"hcexample-kpr-careplan\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-kommune-careplan.html\">no-kommune-CarePlan</a></p></div><p><b>status</b>: Active</p><p><b>intent</b>: Plan</p><p><b>title</b>: Self-care and functional follow-up at home</p><p><b>description</b>: The plan is based on the 17 August assessment and updated after the 31 August home visit. Changes to services require a separate assessment and are not inferred automatically from scores.</p><p><b>subject</b>: <a href=\"Patient-example-patient.html\">Kari Hansen  Female, DoB: 1948-09-12 ( urn:oid:2.16.578.1.12.4.1.4.1#Foedselsnummer#12094812345)</a></p><p><b>encounter</b>: <a href=\"Encounter-example-kpr-followup-encounter.html\">Encounter: status = finished; class = home health (ActCode#HH); type = ; serviceType = Helsetjenester i hjemmet; period = 2026-08-31 09:30:00+0200 --&gt; 2026-08-31 10:30:00+0200</a></p><p><b>period</b>: 2026-08-18 --&gt; (ongoing)</p><p><b>created</b>: 2026-08-17 11:30:00+0200</p><p><b>author</b>: <a href=\"PractitionerRole-example-practitionerrole.html\">PractitionerRole</a></p><p><b>supportingInfo</b>: </p><ul><li><a href=\"Observation-example-kpr-function.html\">Observation Personlig hygiene</a></li><li><a href=\"Observation-example-kpr-mobility.html\">Observation Bevege seg innendørs</a></li><li><a href=\"Observation-example-kpr-vision.html\">Observation Syn</a></li><li><a href=\"Observation-example-kpr-hearing.html\">Observation Hørsel</a></li></ul><p><b>goal</b>: <a href=\"Goal-example-kpr-goal.html\">Goal: lifecycleStatus = active; description = ; start[x] = 2026-08-18</a></p><blockquote><p><b>activity</b></p><p><b>outcomeReference</b>: </p><ul><li><a href=\"Encounter-example-kpr-followup-encounter.html\">Encounter: status = finished; class = home health (ActCode#HH); type = ; serviceType = Helsetjenester i hjemmet; period = 2026-08-31 09:30:00+0200 --&gt; 2026-08-31 10:30:00+0200</a></li><li><a href=\"Observation-example-kpr-followup.html\">Observation Personlig hygiene</a></li></ul><p><b>progress</b>: @2026-08-31 11:30:00+0200</p><blockquote><div><p>Reassessment shows a change from score 3 to 2 for personal hygiene. Review further assistance with Kari. The first assessment and original request basis are retained.</p>\n</div></blockquote><p><b>reference</b>: <a href=\"ServiceRequest-example-kpr-service.html\">ServiceRequest Helsetjenester i hjemmet</a></p></blockquote></div>"
  },
  "status" : "active",
  "intent" : "plan",
  "title" : "Self-care and functional follow-up at home",
  "description" : "The plan is based on the 17 August assessment and updated after the 31 August home visit. Changes to services require a separate assessment and are not inferred automatically from scores.",
  "subject" : {
    🔗 "reference" : "Patient/example-patient"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/example-kpr-followup-encounter"
  },
  "period" : {
    "start" : "2026-08-18"
  },
  "created" : "2026-08-17T11:30:00+02:00",
  "author" : {
    🔗 "reference" : "PractitionerRole/example-practitionerrole"
  },
  "supportingInfo" : [
    {
      🔗 "reference" : "Observation/example-kpr-function"
    },
    {
      🔗 "reference" : "Observation/example-kpr-mobility"
    },
    {
      🔗 "reference" : "Observation/example-kpr-vision"
    },
    {
      🔗 "reference" : "Observation/example-kpr-hearing"
    }
  ],
  "goal" : [
    {
      🔗 "reference" : "Goal/example-kpr-goal"
    }
  ],
  "activity" : [
    {
      "outcomeReference" : [
        {
          🔗 "reference" : "Encounter/example-kpr-followup-encounter"
        },
        {
          🔗 "reference" : "Observation/example-kpr-followup"
        }
      ],
      "progress" : [
        {
          "time" : "2026-08-31T11:30:00+02:00",
          "text" : "Reassessment shows a change from score 3 to 2 for personal hygiene. Review further assistance with Kari. The first assessment and original request basis are retained."
        }
      ],
      "reference" : {
        🔗 "reference" : "ServiceRequest/example-kpr-service"
      }
    }
  ]
}